High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge

Measure Type :

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12-month period who also have a prior MI OR a current or prior LVEF <40% who were prescribed beta-blocker therapy

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#009 Anti-Depressant Medication Management

Description :

Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported:
a Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks)
b Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months)

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) who had a dilated macular examination performed which included documentation of the presence or absence of macular thickening or geographic atrophy or hemorrhage AND the level of macular degeneration severity during one or more office visits within 12 months

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#018 Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy

Description :

Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed which included documentation of the level of severity of retinopathy and the presence or absence of macular edema during one or more office visits within 12 months

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

#021 Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second Generation Cephalosporin

Description :

Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis

NQS Domain :

Patient Safety

Measure Type :

Process

High Priority Measure :

Description :

Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time

NQS Domain :

Patient Safety

Measure Type :

Process

High Priority Measure :

#024 Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older

Description :

Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is reported by the physician who treats the fracture and who therefore is held accountable for the communication

NQS Domain :

Measure Type :

High Priority Measure :

#046 Medication Reconciliation Post-Discharge

Description :

The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record.
This measure is reported as three rates stratified by age group:
• Submission Criteria 1: 18-64 years of age
• Submission Criteria 2: 65 years and older
• Total Rate: All patients 18 years of age and older

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

#047 Care Plan

Description :

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed an long-acting inhaled bronchodilator

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a diagnosis of myelodysplastic syndrome (MDS) who are receiving erythropoietin therapy with documentation of iron stores within 60 days prior to initiating erythropoietin therapy

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#069 Hematology: Multiple Myeloma: Treatment with Bisphosphonates

Description :

Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission, who were prescribed or received intravenous bisphosphonate therapy within the 12 month reporting period

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients aged 18 years and older, seen within a 12 month reporting period, with a diagnosis of chronic lymphocytic leukemia (CLL) made at any time during or prior to the reporting period who had baseline flow cytometry studies performed and documented in the chart

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer

NQS Domain :

Efficiency and Cost Reduction

Measure Type :

Process

High Priority Measure :

#104 Prostate Cancer: Combination Androgen Deprivation Therapy for High Risk or Very High Risk Prostate Cancer

Description :

Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high or very high risk of recurrence receiving external beam radiotherapy to the prostate who were prescribed androgen deprivation therapy in combination with external beam radiotherapy to the prostate

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#107 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

Description :

Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified

NQS Domain :

Measure Type :

High Priority Measure :

#117 Diabetes: Eye Exam

Description :

Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period

Description :

Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy

NQS Domain :

Measure Type :

High Priority Measure :

#122 Adult Kidney Disease: Blood Pressure Management

Description :

Percentage of patient visits for those patients aged 18 years and older with a diagnosis of chronic kidney disease (CKD) (stage 3, 4, or 5, not receiving Renal Replacement Therapy [RRT]) with a blood pressure < 140/90 mmHg OR = 140/90 mmHg with a documented plan of care

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounterNormal Parameters:Age 18 years and older BMI = 18.5 and < 25 kg/m2

NQS Domain :

Community/Population Health

Measure Type :

Process

High Priority Measure :

#130 Documentation of Current Medications in the Medical Record

Description :

Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

NQS Domain :

Community/Population Health

Measure Type :

Process

High Priority Measure :

#137 Melanoma: Continuity of Care – Recall System

Description :

Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month period, into a recall system that includes:
• A target date for the next complete physical skin exam, AND
• A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment

NQS Domain :

Communication and Care Coordination

Measure Type :

Structure

High Priority Measure :

#138 Melanoma: Coordination of Care

Description :

Percentage of patient visits, regardless of age, with a new occurrence of melanoma that have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients aged 50 years and older with a diagnosis of age-related macular degeneration (AMD) or their caregiver(s) who were counseled within 12 months on the benefits and/or risks of the Age-Related Eye Disease Study (AREDS) formulation for preventing progression of AMD

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#141 Primary Open-Angle Glaucoma (POAG): Reduction of Intraocular Pressure (IOP) by 15% OR Documentation of a Plan of Care

Description :

Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (POAG) whose glaucoma treatment has not failed (the most recent IOP was reduced by at least 15% from the pre-intervention level) OR if the most recent IOP was not reduced by at least 15% from the pre-intervention level, a plan of care was documented within 12 months

NQS Domain :

Measure Type :

High Priority Measure :

#144 Oncology: Medical and Radiation – Plan of Care for Pain

Description :

Percentage of visits for patients, regardless of age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy who report having pain with a documented plan of care to address pain

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of final reports for all patients, regardless of age, undergoing bone scintigraphy that include physician documentation of correlation with existing relevant imaging studies (e.g., x-ray, MRI, CT, etc.) that were performed

NQS Domain :

Measure Type :

High Priority Measure :

#156 Oncology: Radiation Dose Limits to Normal Tissues

Description :

Percentage of patients, regardless of age, with a diagnosis of breast, rectal, pancreatic or lung cancer receiving 3D conformal radiation therapy who had documentation in medical record that radiation dose limits to normal tissues were established prior to the initiation of a course of 3D conformal radiation for a minimum of two tissues

NQS Domain :

Measure Type :

High Priority Measure :

#163 Diabetes: Foot Exam

Description :

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year

NQS Domain :

Measure Type :

High Priority Measure :

#166 Coronary Artery Bypass Graft (CABG): Stroke

Description :

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who have a postoperative stroke (i.e., any confirmed neurological deficit of abrupt onset caused by a disturbance in blood supply to the brain) that did not resolve within 24 hours

NQS Domain :

Measure Type :

High Priority Measure :

#168 Coronary Artery Bypass Graft (CABG): Surgical Re-Exploration

Description :

Percentage of patients aged 18 years and older undergoing isolated CABG surgery who require a return to the operating room (OR) during the current hospitalization for mediastinal bleeding with or without tamponade, graft occlusion, valve dysfunction, or other cardiac reason

NQS Domain :

Effective Clinical Care

Measure Type :

Outcome

High Priority Measure :

#176 Rheumatoid Arthritis (RA): Tuberculosis Screening

Description :

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have documentation of a tuberculosis (TB) screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic disease-modifying anti-rheumatic drug (DMARD)

NQS Domain :

Measure Type :

High Priority Measure :

#180 Rheumatoid Arthritis (RA): Glucocorticoid Management

Description :

Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone = 10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#181 Elder Maltreatment Screen and Follow-Up Plan

Description :

Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen

NQS Domain :

Patient Safety

Measure Type :

Process

High Priority Measure :

#182 Functional Outcome Assessment

Description :

Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

#185 Colonoscopy Interval for Patients with a History of Adenomatous Polyps
– Avoidance of Inappropriate Use

Description :

Percentage of patients aged 18 years and older receiving a surveillance colonoscopy, with a history of a prior adenomatous polyp(s) in previous colonoscopy findings, which had an interval of 3 or more years since their last colonoscopy

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

#187 Stroke and Stroke Rehabilitation: Thrombolytic Therapy

Description :

Percentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known well

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#191 Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery

Description :

Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and no significant ocular conditions impacting the visual outcome of surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved within 90 days following the cataract surgery

NQS Domain :

Effective Clinical Care

Measure Type :

Outcome

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who had cataract surgery and had any of a specified list of surgical procedures in the 30 days following cataract surgery which would indicate the occurrence of any of the following major complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound dehiscence

NQS Domain :

Measure Type :

High Priority Measure :

#204 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

Description :

Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antiplatelet during the measurement period

NQS Domain :

Measure Type :

High Priority Measure :

#217 Functional Status Change for Patients with Knee Impairments

Description :

A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO’s (knee ) PROM (patient-reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

NQS Domain :

Communication and Care Coordination

Measure Type :

Outcome

High Priority Measure :

#218 Functional Status Change for Patients with Hip Impairments

Description :

A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO’s (hip) PROM (patient- reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

NQS Domain :

Communication and Care Coordination

Measure Type :

Outcome

High Priority Measure :

Description :

A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO’s (foot and ankle) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

NQS Domain :

Communication and Care Coordination

Measure Type :

Outcome

High Priority Measure :

#220 Functional Status Change for Patients with Lumbar Impairments

Description :

A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality

NQS Domain :

Communication and Care Coordination

Measure Type :

Outcome

High Priority Measure :

#221 Functional Status Change for Patients with Shoulder Impairments

Description :

A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO’s (shoulder) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

NQS Domain :

Communication and Care Coordination

Measure Type :

Outcome

High Priority Measure :

Description :

A self-report outcome measure of functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality

NQS Domain :

Communication and Care Coordination

Measure Type :

Outcome

High Priority Measure :

#223 Functional Status Change for Patients with Other General Orthopaedic Impairments

Description :

A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopaedic impairment). The change in FS assessed using FOTO (general orthopaedic) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality

NQS Domain :

Communication and Care Coordination

Measure Type :

Outcome

High Priority Measure :

#224 Melanoma: Overutilization of Imaging Studies in Melanoma

Description :

Percentage of patients, regardless of age, with a current diagnosis of Stage 0 through IIC melanoma or a history of melanoma of any stage, without signs or symptoms suggesting systemic spread, seen for an office visit during the one-year measurement period, for whom no diagnostic imaging studies were ordered

NQS Domain :

Measure Type :

High Priority Measure :

#238 Use of High-Risk Medications in the Elderly

Description :

Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted.
1) Percentage of patients who were ordered at least one high-risk medication.
2) Percentage of patients who were ordered at least two of the same high-risk medication

NQS Domain :

Patient Safety

Measure Type :

Process

High Priority Measure :

#239 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

Description :

Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported.- Percentage of patients with height, weight, and body mass index (BMI) percentile documentation
- Percentage of patients with counseling for nutrition
- Percentage of patients with counseling for physical activity

NQS Domain :

Community/Population Health

Measure Type :

Process

High Priority Measure :

#240 Childhood Immunization Status

Description :

Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday

NQS Domain :

Community/Population Health

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients evaluated in an outpatient setting who within the previous 12 months have experienced an acute myocardial infarction (MI), coronary artery bypass graft (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery, or cardiac transplantation, or who have chronic stable angina (CSA) and have not already participated in an early outpatient cardiac rehabilitation/secondary prevention (CR) program for the qualifying event/diagnosis who were referred to a CR program

Measure Type :

High Priority Measure :

Description :

This is a measure based on whether quantitative evaluation of Human Epidermal Growth Factor Receptor 2 Testing (HER2) by immunohistochemistry (IHC) uses the system recommended in the current ASCO/CAP Guidelines for Human Epidermal Growth Factor Receptor 2 Testing in breast cancer

NQS Domain :

Effective Clinical Care

Measure Type :

Structure

High Priority Measure :

Description :

Percentage of pregnant female patients aged 14 to 50 who present to the emergency department (ED) with a chief complaint of abdominal pain or vaginal bleeding who receive a trans-abdominal or trans-vaginal ultrasound to determine pregnancy location

NQS Domain :

Measure Type :

High Priority Measure :

#258 Rate of Open Repair of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post-Operative Day #7)

Description :

Percent of patients undergoing open repair of small or moderate sized non-ruptured infrarenal abdominal aortic aneurysms who do not experience a major complication (discharge to home no later than post-operative day #7)

NQS Domain :

Measure Type :

High Priority Measure :

#259 Rate of Endovascular Aneurysm Repair (EVAR) of Small or Moderate Non-Ruptured Infrarenal Abdominal Aortic Aneurysms (AAA) without Major Complications (Discharged to Home by Post Operative Day #2)

Description :

Percent of patients undergoing endovascular repair of small or moderate non-ruptured infrarenal abdominal aortic aneurysms (AAA) that do not experience a major complication (discharged to home no later than post-operative day #2)

Description :

NQS Domain :

Measure Type :

High Priority Measure :

#261 Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness

Description :

Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness

NQS Domain :

Measure Type :

High Priority Measure :

#268 Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

Description :

All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients with an inflammatory bowel disease encounter who were prescribed prednisone equivalents greater than or equal to 10 mg/day for 60 or greater consecutive days or a single prescription equating to 600 mg prednisone or greater for all fills and were documented for risk of bone loss once during the reporting year or the previous calendar year. Individuals who received an assessment for bone loss during the prior or current year are considered adequately screened.

NQS Domain :

Measure Type :

High Priority Measure :

#276 Sleep Apnea: Assessment of Sleep Symptoms

Description :

Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of sleep symptoms, including presence or absence of snoring and daytime sleepiness

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#277 Sleep Apnea: Severity Assessment at Initial Diagnosis

Description :

Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients with dementia for whom there was a documented symptoms screening* for behavioral and psychiatric symptoms, including depression, AND for whom, if symptoms screening was positive, there was also documentation of recommendations for symptoms management in the last 12 months

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening * in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources or orders for home safety evaluation

NQS Domain :

Patient Safety

Measure Type :

Process

High Priority Measure :

#288 Dementia: Caregiver Education and Support

Description :

Percentage of patients with dementia whose caregiver(s)* were provided with education** on dementia disease management and health behavior changes AND were referred to additional resources*** for support in the last 12 months

NQS Domain :

Measure Type :

High Priority Measure :

#293 Parkinson’s Disease: Rehabilitative Therapy Options

Description :

Percentage of all patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the past 12 months

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

#303 Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery

Description :

Percentage of patients aged 18 years and older who had cataract surgery and had improvement in visual function achieved within 90 days following the cataract surgery, based on completing a pre-operative and post-operative visual function survey

NQS Domain :

Person and Caregiver-Centered Experience and Outcomes

Measure Type :

Outcome

High Priority Measure :

#304 Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery

Description :

Percentage of patients aged 18 years and older who had cataract surgery and were satisfied with their care within 90 days following the cataract surgery, based on completion of the Consumer Assessment of Healthcare Providers and Systems Surgical Care Survey

NQS Domain :

Person and Caregiver-Centered Experience and Outcomes

Measure Type :

Outcome

High Priority Measure :

#305 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

Description :

Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported.
a. Percentage of patients who initiated treatment within 14 days of the diagnosis
b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#309 Cervical Cancer Screening

Description :

Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:
* Women age 21-64 who had cervical cytology performed every 3 years
* Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years

NQS Domain :

Measure Type :

High Priority Measure :

#317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Description :

Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients aged 50 to 75 years of age receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA- approved anticoagulant drug for the prevention of thromboembolism during the measurement period

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#327 Pediatric Kidney Disease: Adequacy of Volume Management

Description :

Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) undergoing maintenance hemodialysis in an outpatient dialysis facility have an assessment of the adequacy of volume management from a nephrologist

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

Description :

Percentage of calendar months within a 12-month period during which patients aged 17 years and younger with a diagnosis of End Stage Renal Disease (ESRD) receiving hemodialysis or peritoneal dialysis have a hemoglobin level < 10 g/dL

NQS Domain :

Effective Clinical Care

Measure Type :

Intermediate Outcome

High Priority Measure :

#329 Adult Kidney Disease: Catheter Use at Initiation of Hemodialysis

Description :

Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) who initiate maintenance hemodialysis during the measurement period, whose mode of vascular access is a catheter at the time maintenance hemodialysis is initiated

NQS Domain :

Effective Clinical Care

Measure Type :

Outcome

High Priority Measure :

#330 Adult Kidney Disease: Catheter Use for Greater Than or Equal to 90 Days

Description :

Percentage of patients aged 18 years and older with a diagnosis of End Stage Renal Disease (ESRD) receiving maintenance hemodialysis for greater than or equal to 90 days whose mode of vascular access is a catheter

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis

NQS Domain :

Efficiency and Cost Reduction

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a diagnosis of acute sinusitis who had a computerized tomography (CT) scan of the paranasal sinuses ordered at the time of diagnosis or received within 28 days after date of diagnosis

Measure Type :

High Priority Measure :

Description :

Percentage of patients, regardless of age, who gave birth during a 12-month period who delivered a live singleton at
= 37 and < 39 weeks of gestation completed who had elective deliveries or early inductions without medical indication

NQS Domain :

Patient Safety

Measure Type :

Outcome

High Priority Measure :

#336 Maternity Care: Post-Partum Follow-Up and Care Coordination

Description :

Percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients whose providers are ensuring active tuberculosis prevention either through yearly negative standard tuberculosis screening tests or are reviewing the patient’s history to determine if they have had appropriate management for a recent or prior positive test

NQS Domain :

Measure Type :

High Priority Measure :

#340 HIV Medical Visit Frequency

Description :

Percentage of patients, regardless of age with a diagnosis of HIV who had at least one medical visit in each 6 month period of the 24 month measurement period, with a minimum of 60 days between medical visits

NQS Domain :

Efficiency and Cost Reduction

Measure Type :

Process

High Priority Measure :

#342 Pain Brought Under Control Within 48 Hours

Description :

Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) who report pain was brought to a comfortable level within 48 hours

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke)

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients regardless of age undergoing a total knee replacement whose operative report identifies the prosthetic implant specifications including the prosthetic implant manufacturer, the brand name of the prosthetic implant and the size of each prosthetic implant

#357 Surgical Site Infection (SSI)

Description :

NQS Domain :

Measure Type :

High Priority Measure :

#358 Patient-Centered Surgical Risk Assessment and Communication

Description :

Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon

NQS Domain :

Person and Caregiver-Centered Experience and Outcomes

Measure Type :

Process

High Priority Measure :

Description :

Percentage of computed tomography (CT) imaging reports for all patients, regardless of age, with the imaging study named according to a standardized nomenclature and the standardized nomenclature is used in institution’s computer systems

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

Description :

Percentage of computed tomography (CT) and cardiac nuclear medicine (myocardial perfusion studies) imaging reports for all patients, regardless of age, that document a count of known previous CT (any type of CT) and cardiac nuclear medicine (myocardial perfusion) studies that the patient has received in the 12-month period prior to the current study

NQS Domain :

Patient Safety

Measure Type :

Process

High Priority Measure :

Description :

Percentage of total computed tomography (CT) studies performed for all patients, regardless of age, that are reported to a radiation dose index registry that is capable of collecting at a minimum selected data elements

NQS Domain :

Patient Safety

Measure Type :

Structure

High Priority Measure :

Description :

Percentage of final reports for computed tomography (CT) studies performed for all patients, regardless of age, which document that Digital Imaging and Communications in Medicine (DICOM) format image data are available to non-affiliated external healthcare facilities or entities on a secure, media free, reciprocally searchable basis with patient authorization for at least a 12-month period after the study

NQS Domain :

Communication and Care Coordination

Measure Type :

Structure

High Priority Measure :

Description :

Percentage of final reports of computed tomography (CT) studies performed for all patients, regardless of age, which document that a search for Digital Imaging and Communications in Medicine (DICOM) format images was conducted for prior patient CT imaging studies completed at non-affiliated external healthcare facilities or entities within the past 12-months and are available through a secure, authorized, media-free, shared archive prior to an imaging study being performed

NQS Domain :

Communication and Care Coordination

Measure Type :

Structure

High Priority Measure :

Description :

Percentage of final reports for computed tomography (CT) imaging studies of the thorax for patients aged 18 years and older with documented follow-up recommendations for incidentally detected pulmonary nodules (e.g., follow-up CT imaging studies needed or that no follow-up is needed) based at a minimum on nodule size AND patient risk factors

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

#366 Follow-Up Care for Children Prescribed ADHD Medication (ADD)

Description :

Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported.
a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase
b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended

NQS Domain :

Measure Type :

High Priority Measure :

#372 Maternal Depression Screening

Description :

The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life

NQS Domain :

Measure Type :

High Priority Measure :

#375 Functional Status Assessment for Total Knee Replacement

Description :

Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

NQS Domain :

Person and Caregiver-Centered Experience and Outcomes

Measure Type :

Process

High Priority Measure :

#376 Functional Status Assessment for Total Hip Replacement

Description :

Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

NQS Domain :

Measure Type :

High Priority Measure :

#383 Adherence to Antipsychotic Medications For Individuals with Schizophrenia

Description :

Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Patients aged 18 years and older who had surgery for primary rhegmatogenous retinal detachment and achieved an improvement in their visual acuity, from their preoperative level, within 90 days of surgery in the operative eye

NQS Domain :

Effective Clinical Care

Measure Type :

Outcome

High Priority Measure :

#386 Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences

Description :

Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a diagnosis of hepatitis C with whom a physician or other qualified healthcare professional reviewed the range of treatment options appropriate to their genotype and demonstrated a shared decision making approach with the patient. To meet the measure, there must be documentation in the patient record of a discussion between the physician or other qualified healthcare professional and the patient that includes all of the following: treatment choices appropriate to genotype, risks and benefits, evidence of effectiveness, and patient preferences toward treatment

NQS Domain :

Person and Caregiver-Centered Experience and Outcomes

Measure Type :

Process

High Priority Measure :

#391 Follow-Up After Hospitalization for Mental Illness (FUH)

Description :

The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted:
• The percentage of discharges for which the patient received follow-up within 30 days of discharge.
• The percentage of discharges for which the patient received follow-up within 7 days of discharge.

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

Description :

Rate of cardiac tamponade and/or pericardiocentesis following atrial fibrillation ablation This measure is submitted as four rates stratified by age and gender:
• Submission Age Criteria 1: Females 18-64 years of age
• Submission Age Criteria 2: Males 18-64 years of age
• Submission Age Criteria 3: Females 65 years of age and older
• Submission Age Criteria 4: Males 65 years of age and older

Description :

NQS Domain :

Measure Type :

High Priority Measure :

#395 Lung Cancer Reporting (Biopsy/Cytology Specimens)

Description :

Pathology reports based on biopsy and/or cytology specimens with a diagnosis of primary nonsmall cell lung cancer classified into specific histologic type or classified as NSCLC-NOS with an explanation included in the pathology report

NQS Domain :

Measure Type :

High Priority Measure :

#398 Optimal Asthma Control

Description :

Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation

NQS Domain :

Effective Clinical Care

Measure Type :

Outcome

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945-1965 who received one-time screening for hepatitis C virus (HCV) infection

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C cirrhosis who underwent imaging with either ultrasound, contrast enhanced CT or MRI for hepatocellular carcinoma (HCC) at least once within the 12 month reporting period

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#402 Tobacco Use and Help with Quitting Among Adolescents

Description :

The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of final reports for computed tomography (CT), CT angiography (CTA) or magnetic resonance imaging (MRI) or magnetic resonance angiogram (MRA) studies of the chest or neck for patients aged 18 years and older with no known thyroid disease with a thyroid nodule < 1.0 cm noted incidentally with follow-up imaging recommended

NQS Domain :

Measure Type :

High Priority Measure :

#408 Opioid Therapy Follow-up Evaluation

Description :

All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of psoriasis vulgaris patients receiving oral systemic or biologic therapy who meet minimal physician-or patient- reported disease activity levels. It is implied that establishment and maintenance of an established minimum level of disease control as measured by physician-and/or patient-reported outcomes will increase patient satisfaction with and adherence to treatment

NQS Domain :

Measure Type :

High Priority Measure :

#414 Evaluation or Interview for Risk of Opioid Misuse

Description :

All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#415 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older

Description :

Percentage of emergency department visits for patients aged 18 years and older who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CT

NQS Domain :

Efficiency and Cost Reduction

Measure Type :

Efficiency

High Priority Measure :

#416 Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years

Description :

Percentage of emergency department visits for patients aged 2 through 17 years who presented within 24 hours of a minor blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury

NQS Domain :

Measure Type :

High Priority Measure :

#418 Osteoporosis Management in Women Who Had a Fracture

Description :

The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture

NQS Domain :

Measure Type :

High Priority Measure :

#420 Varicose Vein Treatment with Saphenous Ablation: Outcome Survey

Description :

Percentage of patients treated for varicose veins (CEAP C2-S) who are treated with saphenous ablation (with or without adjunctive tributary treatment) that report an improvement on a disease specific patient reported outcome survey instrument after treatment

NQS Domain :

Effective Clinical Care

Measure Type :

Outcome

High Priority Measure :

Description :

Percentage of patients in whom a retrievable IVC filter is placed who, within 3 months post-placement, have a documented assessment for the appropriateness of continued filtration, device removal or the inability to contact the patient with at least two attempts

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients undergoing carotid endarterectomy (CEA) who are taking an anti-platelet agent within 48 hours prior to surgery and are prescribed this medication at hospital discharge following surgery

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

#424 Perioperative Temperature Management

Description :

Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was achieved within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU or other non-ICU location in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

#427 Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU)

Description :

Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively

NQS Domain :

Patient Safety

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user

NQS Domain :

Measure Type :

High Priority Measure :

#433 Proportion of Patients Sustaining a Bowel Injury at the time of any Pelvic Organ Prolapse Repair

Description :

Percentage of patients undergoing surgical repair of pelvic organ prolapse that is complicated by a bowel injury at the time of index surgery that is recognized intraoperatively or within 1 month after surgery

NQS Domain :

Measure Type :

High Priority Measure :

#435 Quality of Life Assessment For Patients With Primary Headache Disorders

Description :

Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved

NQS Domain :

Effective Clinical Care

Measure Type :

Outcome

High Priority Measure :

Description :

Percentage of final reports for patients aged 18 years and older undergoing CT with documentation that one or more of the following dose reduction techniques were used:
• Automated exposure control
• Adjustment of the mA and/or kV according to patient size
• Use of iterative reconstruction technique

NQS Domain :

Measure Type :

High Priority Measure :

#438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Description :

Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period:
• Adults aged = 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR
• Adults aged =21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level = 190 mg/dL; OR
• Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL

NQS Domain :

Measure Type :

High Priority Measure :

Description :

Percentage of biopsies with a diagnosis of cutaneous Basal Cell Carcinoma (BCC) and Squamous Cell Carcinoma (SCC) (including in situ disease) in which the pathologist communicates results to the clinician within 7 days from the time when the tissue specimen was received by the pathologist

NQS Domain :

Communication and Care Coordination

Measure Type :

Process

High Priority Measure :

Description :

The IVD All-or-None Measure is one outcome measure (optimal control). The measure contains four goals. All four goals within a measure must be reached in order to meet that measure. The numerator for the all-or-none measure should be collected from the organization's total IVD denominator. All-or-None Outcome Measure (Optimal Control) - Using the IVD denominator optimal results include:
+G254
· Most recent blood pressure (BP) measurement is less than 140/90 mm Hg -- And
· Most recent tobacco status is Tobacco Free -- And
· Daily Aspirin or Other Antiplatelet Unless Contraindicated -- And
· Statin Use Unless Contraindicated

NQS Domain :

Effective Clinical Care

Measure Type :

Intermediate Outcome

High Priority Measure :

#442 Persistence of Beta-Blocker Treatment After a Heart Attack

Description :

The percentage of patients 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of acute myocardial infarction (AMI) and who were prescribed persistent beta-blocker treatment for six months after discharge

#443 Non-Recommended Cervical Cancer Screening in Adolescent Females

Description :

NQS Domain :

Measure Type :

High Priority Measure :

#444 Medication Management for People with Asthma

Description :

The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period

NQS Domain :

Efficiency and Cost Reduction

Measure Type :

Process

High Priority Measure :

Description :

Percent of patients aged 18 years and older undergoing isolated CABG who die, including both all deaths occurring during the hospitalization in which the CABG was performed, even if after 30 days, and those deaths occurring after discharge from the hospital, but within 30 days of the procedure

NQS Domain :

Effective Clinical Care

Measure Type :

Outcome

High Priority Measure :

#446 Operative Mortality Stratified by the Five STS-EACTS Mortality Categories

Description :

Percent of patients undergoing index pediatric and/or congenital heart surgery who die, including both 1) all deaths occurring during the hospitalization in which the procedure was performed, even if after 30 days (including patients transferred to other acute care facilities), and 2) those deaths occurring after discharge from the hospital, but within 30 days of the procedure, stratified by the five STAT Mortality Levels, a multi-institutional validated complexity stratification tool

Description :

NQS Domain :

Measure Type :

High Priority Measure :

#458 All-cause Hospital Readmission

Description :

The 30-day All-Cause Hospital Readmission measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized at a short-stay acute care hospital and experienced an unplanned readmission for any cause to an acute care hospital within 30 days of discharge

Measure Type :

High Priority Measure :

Description :

Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT

NQS Domain :

Effective Clinical Care

Measure Type :

Process

High Priority Measure :

Description :

Percentage of patients aged 3 through 17 years, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively and/or intraoperatively

NQS Domain :

Measure Type :

High Priority Measure :

Description :

The percentage of patients with documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries

NQS Domain :

Patient Safety

Measure Type :

Process

High Priority Measure :

#467 Developmental Screening in the First Three Years of Life

Description :

The percentage of children screened for risk of developmental, behavioral and social delays using a standardized screening tool in the 12 months preceding or on their first, second, or third birthday. This is a composite measure of screening in the first three years of life that includes three, age-specific indicators assessing whether children are screened in the 12 months proceeding or on their first, second or third birthday